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Post Natal Depression (PND) Prevention Program GuidelineAdopted: Feb. 2005 Revised: Feb. 2007; Oct 2013 Reviewed: June 2011Physician Contact: Virginia Maxanne Flores, M.D., Michael Hawkins, MD
Depression is very common during pregnancy and the postpartum period. Based on data from the Pregnancy RiskAssessment Monitoring System (PRAMS), reported by the Centers for Disease Control (CDC), the prevalence ofpostpartum depression varies by age, ranging from 10.3% among women aged 30–39 years to 23.3% among womenaged ≤19 years.i
Inconsistent screening practices exist, and postpartum depression screening is not standard care across the board.iCurrently there is insufficient evidence to support a firm recommendation for universal antepartum or postpartumscreening. However, screening for depression has the potential to benefit a woman and her family and should bestrongly considered. Because genuine depression, of a more serious nature than postpartum “blues” may develop,screening in certainly appropriate in patients at apparent risk; women with current depression or a history of majordepression warrant particularly close monitoring and evaluation.i i
There are multiple depression screening tools available for use. These tools usual y can be completed in less than 10minutes. Examples of highly sensitive screening tools include the Edinburgh Postnatal Depression Scale, PostpartumDepression Screening Scale, and Patient Health Questionnaire. i i
Pregnancy and the postpartum period represent an ideal time during which consistent contact with the health caredelivery system wil al ow women at risk to be identified and treated.I. Screening
A. Recommend that all women be routinely assessed during the antenatal period for a history of depression or other
B. Patients should be screened for the symptoms of depression in the postnatal period as a part of a screening program
I . Management
A. PND should be managed in the same way as depression at any other time, but with additional considerations regarding
the use of antidepressants when breast-feeding and in pregnancy. (See Scott & White Health Plan (SWHP) Tier 2Clinical Practice Guideline “Pharmacological Management of Major Depressive Disorder, Non-Psychotic.”)
B. Psychosocial interventions should be considered when deciding on treatment options for a mother diagnosed as
suffering from PND.Note: Patients with bipolar or psychotic symptoms should be referred to Psychiatry. Also suicidal patients should beevaluated for admission, as well as patients who express fears of hurting their baby.I I. Prescribing
A. Establish a clear indication for drug treatment.B. Use treatments in the lowest effective dose.C. Drugs with a better evidence base (generally more established drugs) are preferable.D. Assess the benefit/risk ratio of the il ness and treatment for both mother and baby/fetus, including consideration of:
2X increased risk of congenital heart defects with paroxetine
30% risk of neonatal abstinence syndrome after Selective Serotonin Reuptake Inhibitors (SSRI) exposure inlate pregnancy
6X increased risk to neonate of persistent pulmonary hypertension with SSRI exposure after 20 weeks
E. The risks of stopping tricyclic or SSRI antidepressant medication should be carefully assessed in relation to the
mother’s mental state and previous history. There is no indication to stop tricyclic or SSRI antidepressant medication(EXCEPT PAROXETINE) as a matter of routine in early pregnancy.
F. There is no clinical indication for women treated with TCA’s, paroxetine, sertraline, or fluoxetine to stop breast feeding,
provided the infant is healthy and its progress monitored. Other modern antidepressants are probably also safe duringlactation.Antidepressant Drug information:Rating for use inAdverse effects on breast-fed infantsMedicationDosage range (mg per day)+pregnancy *(NA=Information not available)Selective Serotonin reuptakeinhibitors (SSRI)
Gastrointestinal effects, irritability, insomnia
Somnolence, decreased feeding, weight loss
Tricyclics (tertiary)amitryptyline (Elavil)Tricyclics (secondary)Miscellaneous*--U.S. Food and Drug Administration drug rating for use of drugs in pregnancy: A=No risk in control ed human studies B=no evidence of risk to fetus; C=risk tofetus cannot be ruled out; D=evidence of risk to human fetus; + Adult daily dosages are adapted from AHCPR and women may need lower daily dosages.Guideline based on Recommendations of the Royal College of Physicians, Scotland; US Preventive Health Task Force; and other expert recommendations fromthe American Academy of Family Physicians. Scott and White Physicians from Dept. of Psychiatry, OB-GYN, and Family Medicine participated in thedevelopment and review of this guideline. 2007 reviewed by OB-GYN and Family Medicine physicians of the Scott and White Health Plan Prenatal Team. 2009reviewed by OB-GYN and Family Medicine physicians of the SWHP Prenatal Team, as well as Dept. of Psychiatry, Scott & White Clinics and Health Integrated, Inc.
Yonkers KA, Wisner KL, Stewart DE et al. The management fo depression during pregnancy: a report from the AmericanPsychiatric Association and the American Col ege of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:703-13 (reantepartum mgmt including prescribing guidelines).
i Mental Il ness Surveil ance Among Adults in the United States. Morbidity and Mortality Weekly Report, September 2, 2011.Supplement 60.i Sharr GL, Hal M. A Nurse-led Initiative to Improve Obstetricians’ Screening for Postpartum Depression. Nursing for Women'sHealth, Volume 17, Issue 4, Article first published online: 19 AUG 2013i i Screening for depression during and after pregnancy. Committee Opinion No. 453. American College of Obstetricians andGynecologists. Obstet Gynecol 2010;115:394–5.